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Annals of Dentistry and Oral Health

Open Access | Research Article

Use of short-term orthodontics by the

specialist orthodontist
Bedan Lyanda Musima; Parmjit Singh*
1
General Dental Practitioner, Private Practice, Nairobi, Kenya
2
Principal Lecturer in Orthodontics and Specialist Orthodontist, Department of Orthodontics, BPP University, London, England

*Corresponding Author(s): Parmjit Singh Abstract

Principal Lecturer in Orthodontics and Specialist Ortho- Background and Objective: Short-Term Orthodontic
dontist, Department of Orthodontics, BPP University, 137 treatment (STO) is mainly performed by General Dental
Stamford Street, London, SE1 9NN, England practitioners (GDPs). This study aimed to acquire the orth-
odontic specialist’s knowledge, experience and opinion of
Tel: +44-7808-887-457; STO via a focus group discussion and survey.
Email: parmjitsingh@hotmail.com
Method: A descriptive observational study was under-
taken via a focus group discussion of eight orthodontists fol-
lowed by a survey of 54 orthodontists using an online self-
Received: Aug 30, 2018 administered questionnaire (SurveyMonkey™). Data was
Accepted: Oct 10, 2018 analysed to investigate the role of gender, age and sphere of
Published Online: Oct 18, 2018 practice on the opinion of STO using Fisher’s Exact Testing.
The level of statistical significance was set at 5% (0.05).
Journal: Annals of Dentistry and Oral Health
Publisher: MedDocs Publishers LLC Results: The valid response rate was 50% (n=27). Forty-
one percent (n=11) of the respondents stated that they
Online edition: http://meddocsonline.org/ used STO but there was no statistically significant effect
Copyright: © Singh P (2018). This Article is distributed on gender, age or sphere of practice. Clear aligners (espe-
under the terms of Creative Commons Attribution 4.0 cially Invisalign™) and conventional labial fixed appliances
International License to achieve STO objectives were the most commonly used
systems with most stating that few cases involve STO (<10%)
and the treatment is more of limited objective rather than
Keywords: Short term orthodontics; Limited objective ortho- short-term.
dontics; Invisalign
Conclusion: STO is a useful treatment alternative in the
specialist’s armamentarium as long as the objectives are
clear from the outset to both the patient and practitioner
and an adequately trained operator carries out the proce-
dure. There is definitely an increase in acceptance and use
of STO especially clear aligners by the specialist commu-
nity.

Introduction
STO is a term used to describe an orthodontic treatment mo-
dality whose main aim is to improve the patient’s smile by align-
ing the anterior teeth i.e. the ‘social six’ [1] whilst not correcting
the posterior malocclusions or aiming to achieve Andrew’s Six
Keys of Normal Occlusion. The treatment time usually does not
last more than nine months [2].
The orthodontic community has experienced a continued
rise of adult patients as a percentage of the total number of pa-
tients seeking orthodontic interventions to improve their smiles
[3]. This may be due to greater availability, awareness and un-
derstanding of the benefits of orthodontic treatment, and the
development of a wide array of acceptable appliance systems.

Cite this article: Musima BL, Singh P. Use of Short-Term Orthodontics by the Specialist Orthodontist. Ann Dent
Oral Health. 2018; 2: 1007.

1

STO origins can probably be traced back to the United States
of America, when in 1997, the Invisalign™ aligner system was
marketed to specialist orthodontists, however, following it’s
popularity and demand, it was made available to general den-
tists two years later [4]. Other companies came up with their
STO systems and some of these include Inman Aligner™, Six
Months Smile™ and Fast Braces™. These treatment modalities
then spread to the United Kingdom and the rest of the world
with increasing popularity in the 2000s.
This popularity has also resulted in a corresponding increase
in litigation. The rate of professional misconduct increased from
2.9% in 2005 to 20% in 2015 as a result of aligner treatment
alone and of these cases, 80-90% of the treatments were per-
formed by GDPs [6].
Reducing the risk of litigation should involve prospective
patients being given sufficient information about all the vari-
ous treatment options available including the pros and cons
for each. There is currently a drive to refer to STO as Limited
Objective Orthodontics (LOO) so that the patient understands
from the outset that their treatment is a compromise and not
comprehensive [7].
Even with such a change in terminology, there are other po-
tential challenges with STO. Some have suggested that in cases
of relapse following STO, retreatment may result in a signifi-
cant increase in the risk and extent of root resorption [8] that
is thought to be due to the use of orthodontic jiggling forces [9]
and therefore compromising the long-term health of the teeth.
As regards relapse, if it occurs, the patient may not be inclined
to undergo another round of treatment (whether STO or com-
prehensive) and instead opt for restorative camouflage which
may end up being more destructive to the tooth structure than
would have been originally [10].
Given the benefits as well as the challenges of STO, the aim
of this study was to acquire knowledge, experience and opinion
of STO use by the specialist orthodontic community via a focus
group discussion followed by a survey.
Materials and method
A descriptive observational study via a focus group discussion
of eight orthodontists known to the authors followed by a pilot
survey of 54 orthodontists was carried out between August and
September 2017 through an online self-administered question-
naire (SurveyMonkey™). Since this was a pilot study that would
help ensure the validity of the questionnaire, a larger sample
size was not considered necessary.
The inclusion criterion was any orthodontist registered as a
specialist with the General Dental Council (GDC) at the time the
research project obtained ethical approval. Participants had to
be living and practising in the United Kingdom (UK). The exclu-
sion criterion was any orthodontist currently undergoing pro-
fessional misconduct investigations.
Approval for the study was sought and granted by BPP Uni-
versity Research Ethics Committee. No personal data of the
participants was collected with only basic non-identifying data
gathered including gender, age group and years practising or-
thodontics.
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The focus group was able to ensure the questionnaire was
clear and unambiguous and properly validated. To ensure that
the focus group discussion was as representative as possible,
the eight participants were chosen from various spheres of
practice i.e. National Health Service (NHS) practice, private prac-
tice, hospital practice and academic practice with most (n=5) of
them practicing in two or more of the above spheres.
A convenience sampling method was employed both in the
focus group discussion and in the survey hence the risk of sam-
pling bias was more pronounced though this was mitigated as
much as possible by ensuring that the participants came from
different age sets, gender, geographical locations and spheres
of practice to ensure the data generated was as inclusive as pos-
sible.
The questionnaire had a total of eighteen questions that
were divided into four broad thematic areas of demographics
of the participants, knowledge of STO, experience (if any) in
providing STO and lastly the participant opinion as regards STO.
Fifteen of the eighteen questions were closed ended while the
remaining three were open ended. This meant the majority of
the data collected was quantitative rather than qualitative.
The null hypothesis was that there was no difference in gen-
der, age or practice setting on STO use by specialist orthodon-
tists. Despite there being no direct cause and effect relationship
hence no independent, dependent and controlling variables per
se in this survey, the questionnaire questions were construed to
be the independent variable while the responses as the depen-
dent variable and the specialist orthodontists as the controlled
variable.
Data collection and collation including descriptive statistics
was completed automatically via SurveyMonkey™ in the form
of ratios and percentages. To investigate the role of gender, age
and sphere of practice on their opinion of STO, analytical statis-
tics was undertaken by using Fisher’s Exact Test. The analytical
statistics was completed using Prism Graph Pad (Graph Pad, CA,
USA). The level of statistical significance was set at 5% (0.05).
Results
Fifty-four specialist orthodontists were sent the question-
naire via a SurveyMonkey web link with a reminder being sent
two-weeks later to non-responders. The response rate was 50%
(n= 27) and the completion rate of the online questionnaire was
100%.
The gender of the participants who completed the question-
naire was 52% males (n=14) and 48% females (n=13), with 48%
(n=13) of the participants falling below of 40 years of age and
most having practised orthodontics for between 6 and 15 years
(67%,n=18).
As regards the sphere of practice, the majority of participants
worked in private practice and either NHS practice or hospital
settings. Since a significant number of participants worked in
multiple practice settings, the total number of responses ex-
ceeded 27. Table 1 shows the demographics of the study par-
ticipants.
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Table 1: Participant’s demographics (since most partici-

pants worked in more than one practice setting, the total re-
sponses exceeds 27 for practice setting).

Females 13
Gender
Males 14

<30 0

31-35 3

36-40 10

41-45 8

46-50 1 Figure 2: Influence of age on offering short-term orthodontic

Age (Years) treatment (STO).
51-55 1

56-60 1

61-65 1

66-70 1

˃70 1

NHS Practice 15

Private Practice 23
Practice Setting Hospital Practice 14

Academic
2
Practice

For analytical statistics, due to the small sample size, Fisher’s

Exact Testing was used to test for any statistically significant
correlation of STO usage with the three parameters of gender
(Figure 1), age of the specialists (Figure 2) and practice setting
(Figure 3). No statistical significance was identified for any of
the variables (Table 2) although the trends were that older par-
ticipants were more likely to provide STO as well as those work-
ing in NHS practice or private practice.
Figure 3: Influence of practice setting on offering short-term
orthodontic treatment (STO) (since some participants worked in
more than one practice setting, the total number exceeds 27 re-
spondents).
Table 2: Statistical analysis on influence of gender, age and prac-
tice setting on offering short-term orthodontics.

Fisher’s Exact Test

Male = 14 Female = 13 p value

Gender STO offered = 6 STO offered = 5

1.0000
STO not offered = 8 STO not offered = 8

Under 40 years = 13 Over 41 years = 14

Age STO offered= 4 STO offered= 7 0.4401

STO not offered = 9 STO not offered = 7

STO offered= 8
NHS Practice = 15
STO not offered= 7
Figure 1: Influence of gender on offering short-term orthodon- STO offered= 11
tic treatment (STO). Private Practice = 23
Practice STO not offered= 12
0.3112
Setting STO offered= 3
Hospital Practice = 14
STO not offered= 11

STO offered= 1
Academic Practice = 2
STO not offered= 1

Annals of Dentistry and Oral Health 3


Forty-one percent (n=11) of participants reported using at
least one STO system even though STO cases made up less than
10% of their total treatment cases. Of the participants who
used STO systems, clear aligners and conventional labial fixed
appliances to achieve STO objectives were the most commonly
used systems (Figure 4) with patient satisfaction (39%), clinical
results (22%) and cost (11%) playing a major role in the clini-
cian’s choice of using a certain system.
Figure 4: Most commonly used short-term orthodontic systems
(since some participants used more than one type of system, the
total number exceeds 11 respondents).
Most participants (78%, n=21) felt that treatment duration
and marketing information by the various STO providers are the
two most important determinants for patients seeking STO.
Seventy-eight percent of the participants (n=21) felt that
there was no major difference in the consenting process when
using STO versus conventional fixed orthodontics. The aver-
age duration of STO performed by the participants was found
to range between 3 to 12 months with the mean being 7.9
months. The use of combination treatments (different systems
for the upper and lower arches) was not popular with the par-
ticipants (30%, n=8).
The majority of participants (59%, n=16)stated that there
was no significant difference in the retention protocol they fol-
lowed when performing STO as compared to conventional fixed
orthodontics. Patient’s aged between 31-40 years (67%, n=18)
were the most commonly treated using the STO systems fol-
lowed by those aged 21-30 years (22%, n=6).
Of the participants who used STO (41%, n=11), most stat-
ed that in the very few cases that these systems are used, the
treatment is of limited objective rather than short-term, and it
is not system dependent but rather a treatment planning deci-
sion which entails careful case selection and is usually not the
first line treatment but rather in slight relapse cases, mild mal-
occlusions or to facilitate restorative work.
 Discussion
The overall response rate of 50% (n=27) for the study was
quite encouraging considering that a similar study of STO use by
GDPs had a response rate of 14% [11]. On gender characteris-
tics, 52% (n=14) of the respondents were male and 48% (n=13)
female. This near parity in the gender divide agrees with the re-
ported increase in the proportion of UK registered female den-
tists in general and orthodontists in particular over the years
[12] As regards age, 48% (n=13) of the participants were below
40 years of age while 52% (n=14) were above 40 years with the
mean age being 43.9 years (SD 2.04) which is consistent with
Annals of Dentistry and Oral Health
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The Report of the Orthodontic Workforce Survey of the United
Kingdom of 2005 which stated than the mean age of the spe-
cialist orthodontist was 45.4 years [13]. On practice setting,
nearly all participants worked in more than one setting with pri-
vate practice (n=23), NHS practice (n=15) and hospital practice
(n=14) being the most popular which is also similar to the 2005
Orthodontic Survey which found that the majority of the orth-
odontic workforce worked in more than one setting [13].
Fisher’s Exact Testing was performed to test for any statisti-
cally significant correlation between STO usage with the three
parameters of participant gender, age and practice setting;
however, all were found to be non-significant. The possible rea-
son for this may be the small sample size of the study hence
inherent differences in gender, age and practice setting on STO
use could not be easily identified. Another possible explanation
could be that since most specialists received almost uniform
training in orthodontics, they were well aware of the capabili-
ties and limitations of STO regardless of their gender, age or
practice setting.
Only 40% (n=11) of the participants used at least one STO
system and this constituted less than 10% of their total orth-
odontic treatment cases. This shows that even though STO is
a rapidly developing field in orthodontics, it is yet to achieve
mainstream adoption by specialists. This is especially true since
the majority of the respondents worked in a private practice
setting (and either NHS practice or hospital), hence, it is safe
to postulate that even though a large number of their patients
were paying for the treatments privately, and hence offered the
flexibility to have STO options, over 90% of the treatments done
by these participants were still conventional orthodontic treat-
ment.
Clear aligners (especially Invisalign™) and conventional la-
bial fixed appliances to achieve STO objectives proved to be the
most commonly used STO systems. The use of the latter can be
said to be the reason why there has been a push currently from
the orthodontic community, including the British Orthodontic
Society, to refer to STO as more appropriately Limited Objective
Orthodontics (LOO), sometimes also referred to as adjunctive
treatment [14]. Even though a fixed orthodontic appliance is
being used, the objectives are of a limited nature and the treat-
ment is for a short period unlike the conventional treatment
cycle which hopes to achieve Andrews Six Keys of Normal Oc-
clusion at all times and in which the treatment duration is al-
most invariably longer.
The majority of the specialists who used STO systems also
stated that patient satisfaction and clinical results are the two
most important considerations for them when choosing an STO
system. This may be due to the current paradigm shift in den-
tistry as a whole and orthodontics in particular to being more
patient-centred with aesthetics of the orthodontic appliance
playing a key role in patient attractiveness and hence choice of
treatment [15].
Conversely, most participants felt that the treatment dura-
tion and marketing information are the two most important
factors that influence a patient’s decision on choosing an STO
system. The former partly explains the rise of STO which is tout-
ed as being a ‘quick fix’ in achieving the orthodontic objectives
which tends to particularly appeal to adult patients who are
more willing to undergo the short orthodontic treatments that
STO provides to improve their smiles but are hesitant to under-
go lengthy conventional orthodontic treatment [2]. Indeed, in
4

this study, the average duration of treatment provided by the
specialists performing STO ranged between 3-12 months with
the mean time being 7.9 months. Furthermore, the advertising
spend for cosmetic dental procedures has been increasing in the
UK over the years with STO companies not being left behind and
this may be resulting in patients demanding certain systems in
the orthodontic office rather than a certain outcome/objective.
Indeed, the popularity of clear aligners especially Invisalign™ as
an STO system has been as a result of a strong brand presence
and advertising directly to patients.
Lastly, the majority of patients seeking STO were aged be-
tween 31-40 years (67%, n=18) followed by those aged 21-30
years (22%, n=6). This confirms the belief that STO are mainly
sought by adults who for one reason or another did not have
treatment when they were teenagers or have had relapse of
their originally treated malocclusions. These patients may not
be willing to undergo comprehensive orthodontic correction
lasting for between 18-24 months but are more amenable to
limited orthodontic correction especially of the ‘social six’ teeth
that can be performed in less than 9 months. Another reason
for this may be that most specialists recommend comprehen-
sive orthodontic treatment for younger (adolescent) patients
and only offer STO as an option for adult patients.
Although the opinion as regards STO was quite diverse with
more than half of the participants (59%, n=16) stating that they
did not use any STO systems compared to those who use them
(41%, n=11), there was general consensus on certain key issues.
On treatment consent, the majority of participants felt that
there was no difference in the consenting process in STO versus
conventional orthodontic treatment. This may be due to the
fact that most specialists are quite clear on the objectives of the
proposed treatment suggested to the patient from the outset
and hence offer the option of STO only when they are sure it
will meet the intended objective. This is especially important
because overselling of STO systems without a properly thought
out treatment plan may produce a less than ideal occlusion post
treatment and could result in an unhappy patient and unwant-
ed litigation [6].
Similar to the consent response, the majority of participants
stated that they did not have any difference in retention proto-
col when carrying out STO or conventional orthodontic treat-
ment. This may be because by undertaking proper treatment
planning, it is ensured that when STO is offered as an alterna-
tive, it will be able to achieve the stated objective in the long
term and the corrected occlusion is placed in a zone of stability.
Therefore, the retention follow up after treatment of only 1-2
years (89%, n=24) as stated by the majority of participants is
quite similar to the retention follow up for conventional orth-
odontic treatment.
The main limitation of this study was the sampling bias in
the focus group discussion and the survey. However, this was
mitigated as much as possible by ensuring that the participants
came from different age sets, gender, geographical locations
and spheres of practice to ensure the data generated was as
representative as possible. Nevertheless, the number of regis-
tered orthodontic specialists in the UK is close to 2,000 and yet
the survey sampled a total of only 54.
Another limitation was the lack of similar research done on
the orthodontic community previously that would have en-
abled easy comparison of the results. Indeed, the closest study
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was one carried out on GDPs [11], hence even though there was
some issues with shared commonality between the two stud-
ies, most of the questions raised in the present study had no
direct comparison with the study carried out on GDPs.
Conclusion
The results suggest that STO is a useful treatment alternative
in the specialist’s armamentarium as long as the objectives are
clear from the outset to both the patient and practitioner and
an adequately trained practitioner carries out the procedure.
The results also show a definite increase and continuous accep-
tance of STO especially clear aligners by the specialist commu-
nity with most of them recommending STO only for adults and
not for growing (adolescent) patients for whom they feel that
comprehensive orthodontic treatment is most appropriate. Fi-
nally, the null hypothesis (that there is no difference in gender,
age or practice setting and STO use by specialist orthodontists)
was upheld though this may be due to the small sample size.
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